Medical Cannabis Intake Form
(443) 252-8005 * 1200 Brass Mill Road, Suite B. Belcamp, MD 21017
Demographics
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date of Birth
MMCC ID#
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Email
example@example.com
Indication(s) for Cannabis treatment: Chief complaint/symptoms
What makes your medical condition better, and what makes it worse? Does it interfere with your ability to function? please describe.
When and how did this condition start?
What treatments have you tried and how well have they worked?
Medical History:
Please list any Major Health problems/Hospitalizations & Ongoing (chronic) Medical conditions:
Please list any past Surgeries & When it took place:
OTHER SYMPTOMS
(Please circle any that you have experienced in the last 2 weeks):
General:
Persistent Fatigue
Weakness
Fever/chills
Night Sweats
Dizzy
Fainting
Weight loss/gain
Swollen glands
Head:
Headaches
Eye Pain
Trouble Seeing
Trouble Hearing
Nasal Congestion
Dental Pain
Sore Throat
Breathing:
Cough
Excessive Phlegm
Bloody Phlegm
Shortness of breath
Wheezing
Heart & Circulation:
Chest Pain
Swollen legs/ankles
Difficulty walking up stairs
Leg cramps after walking
Palpitations
Trouble breathing when laying flat
Digestive:
Acid Reflux
Abdominal Pain
Poor appetitie
Nausea/ Vomiting
Constipation
Diarrhea
Blood in vomit or stool
Black or Tarry stools
Excessive belching or passing gas
Rectal pain
Urinary:
Pain/Burning with Urination
Frequent Urination
Leaking of urine
Blood in Urine
Decreased urine stream
Musculoskeletal:
Back Pain
Painful muscles/tendons
Painful Joints
Swollen Joints
Morning Stiffness
Muscle cramping
Rib pain
Pain that comes & goes with movement w/out an apparent reason
Neurological:
RadiatingPain
Tingling
Numbness
Weakness
Blackouts
Tremors
Seizures
Trouble with Balance/ Coordination
Trouble with Memory/ Concentration
Trouble processing numbers
Mental Health:
Persistent Sadness
Worry
Anxiety
Guilt
Fear/Paranoia
Over-energized
Unprovoked mood swings
Panic Attacks
Irritability
Flashbacks
Over/under Eating
Wanting to harm myself or others
Other:
Heat/Cold Intolerance
Excessive Sweating
Changes in appetite or thirst
Skin Changes/Rashes
For WOMEN:
Irregular bleeding
Problems with Periods
Lumps in Breast(s)
Vaginal Dryness
Hot flashes
For MEN:
Erection Problems
Lumps/Pain in Testicles
Do you currently have a Primary Care Provider?
Yes
No
Please List other medical providers that are currently involved with your care:
Please list your CURRENT Medications & Dosages:
This includes Supplements, Herbs, and Over the Counter Medications
Please list any Allergies (Medication, food, or environmental & your reactions):
Cannabis History
Are you currently using Cannabis? (If no, please skip this section next section).
*
Yes
No
How are you using Cannabis? (select all that apply)
Pipe
Joint
Vaporizer
Pen
tincture
Edible
Tea
Topical
Concentrates
Other
How much do you use? (e.g. 20mg CBD 3x/day, or 2 puffs 2x/day, or 1/4 oz/week)
How does Cannabis help you?
Have you had any negative effects from cannabis?
Yes
No
If Yes, please describe:
Submit
Should be Empty: